Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a cognitively intact resident who required supervision with ADLs and had diagnoses including COVID-19, depression, and macular degeneration. The resident was admitted on 09/10/25 and discharged on 09/30/25, leaving against medical advice at the request of the resident’s representative. At discharge, an LPN mistakenly provided the resident’s representative with another resident’s medications and written discharge instructions. The error was not identified until shift change when the night shift nurse could not locate the other resident’s medications in the medication cart. The other resident, admitted on 09/17/25 with diagnoses including cerebral infarction, seizures, and sepsis and with multiple active medication orders, remained in the facility. The resident’s representative discovered that the medications and discharge instructions belonged to a different resident and reported concerns about the resident’s care to the police the following day. The representative informed the police that the facility had acknowledged the error when she called and had asked her to return the medications and discharge instructions so they could be exchanged for the correct ones. A police officer accompanied the representative back to the facility, where the exchange occurred without issue, and the representative confirmed that none of the incorrect medications had been administered to the resident. The Administrator and DON reported that nursing staff realized the error approximately two to three hours after the resident left the facility. Review of the facility’s Discharge/Transfer policy showed that the facility was required to develop and implement a discharge planning process involving the resident or representative and the interdisciplinary team to ensure the resident’s needs were identified and there was a safe transition to a location that met the resident’s needs.
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